We are living in exciting times, a time when HIV can be prevented using a daily pill called oral pre-exposure prophylaxis (PrEP). With close to 7.9 million people living with HIV in South Africa, of which 90% know their status, more innovative prevention options such as oral PrEP are needed to reduce the number of new HIV infections.
No matter how effective oral PrEP is at reducing the risk of HIV infection, it does not offer protection against sexually transmitted infections (STIs) or prevent unplanned pregnancies. For this reason, oral PrEP should be used with a condom whenever possible to maximise protection. Since there is no single HIV prevention option that can provide 100% protection, a combination of prevention methods is essential. These combinations have the power, when used correctly, to help individuals protect themselves against HIV.
A little bit of background
In 2018, the Wits Reproductive Health and HIV Institute (Wits RHI), a leading partner of the OPTIONS Consortium*, in partnership with the National Department of Health and the Clinton Health Access Initiative, developed a research approach to understand exactly why people choose to use this fairly new HIV prevention method, what motivated them to continue using it and if they did stop, why they decide to do so.
During this research, we listened to 299 clients seeking health services at clinics from four provinces (Gauteng, Limpopo, KwaZulu Natal and the Western Cape) across South Africa. We heard from clients either using oral PrEP, had used oral PrEP in the past, had never even heard of it or had heard of oral PrEP but chose not to take it. More than 60% of the clients we spoke with were female and just over 30% were male, that’s right, oral PrEP works for both men and women. Almost half of the clients who shared their thoughts with us were between 25 and 34 years old, but those older and younger shared their thoughts as well.
We explored the effects of oral PrEP use on simultaneous condoms use and other prevention methods and services such as family planning. Of the clients we spoke to, 86% of them had tested for HIV at least once the past 6 months. We also found that, clients were involved in different kinds of relations and either had a main partner or casual partner. The majority (65%) were single or never married, many (30%) were in relationships while a few (3%) were married.
So… were clients more likely to use a condom with their main or casual partner?
We found that oral PrEP clients were more likely to use a condom with their casual partner but not necessarily with their main partner. In fact, we found that clients did not often use condoms with their main partners and that using a condom was challenging in many of these relationships.
One client who had never used oral PrEP said, “I am a sex worker, but I have a boyfriend as well…. I told him that I will use a condom with other people, but he and I don’t use a condom…We have both gone for tests and we are both HIV negative and, so we stopped using a condom.”
Further conversations revealed that condom use was highest among people using oral PrEP and those that had never used oral PrEP compared to past oral PrEP users.
“…and using PrEP doesn’t mean you don’t use a condom as well especially if we came back drunk from partying. I would still need to be comfortable and enjoy our sex safely, and also for his safety but still make him feel I’m his loving fiancée as well, ” said current oral PrEP user.
What about oral PrEP and condom use… did clients use both options together?
For this question, we specifically spoke to current oral PrEP users, who initially told us that they found it easy enough to use oral PrEP and condoms simultaneously. Going deeper into this conversation it did, however come to light that sexual partners would occasionally insist on removing a condom or offer money to encourage sex without condoms.
One of the current oral PrEP users we spoke to said they did not tell their other sexual partners about using oral PrEP because, “…then they’ll want to change your mind or tempt you into sexing without a condom by offering you more money, saying things like ‘but you are protected from infections and my own status is negative…so let’s just do it skin to skin.’ No way I’m not protecting myself although more money is tempting.”
When we asked clients whether they preferred oral PrEP to condoms, most (70%) stated their preference for a combination of both. Others (18%) favoured oral PrEP over condoms; and a few (12%) chose condoms over oral PrEP.
We are the generation that will end HIV…
Oral PrEP is a great HIV prevention option, but it is not a magic bullet. Even with more than 90% protection against HIV, oral PrEP works best when combined with other prevention methods such as condoms and contraception. Although this study found that clients were comfortable using oral PrEP and condoms, there’s a few things we still don’t know - such as whether or not clients who found it hard to use PrEP also found it hard to use other HIV prevention methods like condoms. This leads us to consider whether some clients just naturally need more support to stick with prevention methods. It’s possible that methods requiring consistent attention from the user are just not right for everyone.
Have more questions? Visit myprep.co.za to answer all your questions. Want even more interaction, visit the South Africa MyPrEP Facebook and Twitter pages and join a community of people who believe that We Are The Generation That Will End HIV!
Want oral PrEP? Find your closest clinic in South Africa that is providing oral PrEP free of charge here. Want to know if PrEP is right for you? Try doing this online journey to find out: PrEP Roadmap.
Other blogs in this series:
ACCESS PrEP blog series: Oral PrEP – The pill with a big heart
ACCESS PrEP blog series: Slaying side effects - it’s all about managing the menace
ACCESS PrEP blog series: Oral PrEP health providers have their say - opinions, thoughts and experiences
*The OPTIONS Consortium is one of five microbicide projects funded by the U.S. Agency for International Development (USAID), in partnership with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), working to accelerate and sustain access to PrEP.
Disclaimer: Oral PrEP is more than 90% effective at preventing HIV infection for HIV negative people only. It does not protect against other STIs or unintended pregnancy.
 Avert. HIV and AIDS in South Africa. http://bit.ly/30XIKPM